The damage that the human body can survive these days is as awesome asit is horrible: crushing, burning, bombing, a burst blood vessel inthe brain, a ruptured colon, a massive heart attack, rampaginginfection. These conditions had once been uniformly fatal. Nowsurvival is commonplace, and a large part of the credit goes to theirreplaceable component of medicine known as intensive care.

It's an opaque term. Specialists in the field prefer to call what theydo "critical care," but that doesn't exactly clarify matters. Thenon-medical term "life support" gets us closer. Intensive-care unitstake artificial control of failing bodies. Typically, this involves apanoply of technology—a mechanical ventilator and perhaps atracheostomy tube if the lungs have failed, an aortic balloon pump ifthe heart has given out, a dialysis machine if the kidneys don't work.When you are unconscious and can't eat, silicone tubing can besurgically inserted into the stomach or intestines for formulafeeding. If the intestines are too damaged, solutions of amino acids,fatty acids, and glucose can be infused directly into the bloodstream.

The difficulties of life support are considerable. Reviving a drowningvictim, for example, is rarely as easy as it looks on television,where a few chest compressions and some mouth-to-mouth resuscitationalways seem to bring someone with waterlogged lungs and a stilledheart coughing and sputtering back to life. Consider a case report inThe Annals of Thoracic Surgery of a three-year-old girl who fell intoan icy fishpond in a small Austrian town in the Alps. She was lostbeneath the surface for thirty minutes before her parents found her onthe pond bottom and pulled her up. Following instructions from anemergency physician on the phone, they began cardiopulmonaryresuscitation. A rescue team arrived eight minutes later. The girl hada body temperature of sixty-six degrees, and no pulse. Her pupils weredilated and did not react to light, indicating that her brain was nolonger working.

But the emergency technicians continued CPR anyway. A helicopter tookher to a nearby hospital, where she was wheeled directly to anoperating room. A surgical team put her on a heart-lung bypassmachine. Between the transport time and the time it took to plug theinflow and outflow lines into the femoral vessels of her right leg,she had been lifeless for an hour and a half. By the two-hour mark,however, her body temperature had risen almost ten degrees, and herheart began to beat. It was her first organ to come back.

After six hours, her core temperature reached 98.6 degrees. The teamtried to put her on a breathing machine, but the pond water haddamaged her lungs too severely for oxygen to reach her blood. So theyswitched her to an artificial-lung system known as ECMO—extracorporealmembrane oxygenation. The surgeons opened her chest down the middlewith a power saw and sewed lines to and from the ECMO unit into heraorta and her beating heart. The team moved the girl into intensivecare, with her chest still open and covered with plastic foil. A daylater, her lungs had recovered sufficiently for the team to switch herfrom ECMO to a mechanical ventilator and close her chest. Over thenext two days, all her organs recovered except her brain. A CT scanshowed global brain swelling, which is a sign of diffuse damage, butno actual dead zones. So the team drilled a hole into the girl'sskull, threaded in a probe to monitor her cerebral pressure, and keptthat pressure tightly controlled by constantly adjusting her fluidsand medications. For more than a week, she lay comatose. Then, slowly,she came back to life.

First, her pupils started to react to light. Next, she began tobreathe on her own. And, one day, she simply awoke. Two weeks afterher accident, she went home. Her right leg and left arm were partiallyparalyzed. Her speech was thick and slurry. But by age five, afterextensive outpatient therapy, she had recovered her facultiescompletely. She was like any little girl again.

What makes her recovery astounding isn't just the idea that someonecould come back from two hours in a state that would once have beenconsidered death. It's also the idea that a group of people in anordinary hospital could do something so enormously complex. To savethis one child, scores of people had to carry out thousands of stepscorrectly: placing the heart-pump tubing into her without letting inair bubbles; maintaining the sterility of her lines, her open chest,the burr hole in her skull; keeping a temperamental battery ofmachines up and running. The degree of difficulty in any one of thesesteps is substantial. Then you must add the difficulties oforchestrating them in the right sequence, with nothing dropped,leaving some room for improvisation, but not too much.

For every drowned and pulseless child rescued by intensive care, thereare many more who don't make it—and not just because their bodies aretoo far gone. Machines break down; a team can't get moving fastenough; a simple step is forgotten. Such cases don't get written up inThe Annals of Thoracic Surgery, but they are the norm. Intensive-caremedicine has become the art of managing extreme complexity—and a testof whether such complexity can, in fact, be humanly mastered.

On any given day in the United States, some ninety thousand people arein intensive care. Over a year, an estimated five million Americanswill be, and over a normal lifetime nearly all of us will come to knowthe glassed bay of an I.C.U. from the inside. Wide swaths of medicinenow depend on the lifesupport systems that I.C.U.s provide: care forpremature infants; victims of trauma, strokes, and heart attacks;patients who have had surgery on their brain, heart, lungs, or majorblood vessels. Critical care has become an increasingly large portionof what hospitals do. Fifty years ago, I.C.U.s barely existed. Today,in my hospital, a hundred and fifty-five of our almost seven hundredpatients are, as I write this, in intensive care. The average stay ofan I.C.U. patient is four days, and the survival rate is eighty-sixper cent. Going into an I.C.U., being put on a mechanical ventilator,having tubes and wires run into and out of you, is not a sentence ofdeath. But the days will be the most precarious of your life.

A decade ago, Israeli scientists published a study in which engineersobserved patient care in I.C.U.s for twenty-four-hour stretches. Theyfound that the average patient required a hundred and seventy-eightindividual actions per day, ranging from administering a drug tosuctioning the lungs, and every one of them posed risks. Remarkably,the nurses and doctors were observed to make an error in just one percent of these actions—but that still amounted to an average of twoerrors a day with every patient. Intensive care succeeds only when wehold the odds of doing harm low enough for the odds of doing good toprevail. This is hard. There are dangers simply in lying unconsciousin bed for a few days. Muscles atrophy. Bones lose mass. Pressureulcers form. Veins begin to clot off. You have to stretch and exercisepatients' flaccid limbs daily to avoid contractures, give subcutaneousinjections of blood thinners at least twice a day, turn patients inbed every few hours, bathe them and change their sheets withoutknocking out a tube or a line, brush their teeth twice a day to avoidpneumonia from bacterial buildup in their mouths. Add a ventilator,dialysis, and open wounds to care for, and the difficulties onlyaccumulate.

The story of one of my patients makes the point. Anthony DeFilippo wasa forty-eight-year-old limousine driver from Everett, Massachusetts,who started to hemorrhage at a community hospital during surgery for ahernia and gallstones. The bleeding was finally stopped but his liverwas severely damaged, and over the next few days he became too sickfor the hospital's facilities. When he arrived in our I.C.U., at 1:30A.M. on a Sunday, his ragged black hair was plastered to his sweatyforehead, his body was shaking, and his heart was racing at a hundredand fourteen beats a minute. He was delirious from fever, shock, andlow oxygen levels.

"I need to get out!" he cried. "I need to get out!" He clawed at hisgown, his oxygen mask, the dressings covering his abdominal wound.

"Tony, it's all right," a nurse said to him. "We're going to help you.You're in a hospital."

He shoved her—he was a big man—and tried to swing his legs out of thebed. We turned up his oxygen flow, put his wrists in cloth restraints,and tried to reason with him. He eventually let us draw blood from himand give him antibiotics.

The laboratory results came back showing liver failure, and a wildlyelevated white-blood-cell count indicating infection. It soon becameevident from his empty urine bag that his kidneys had failed, too. Inthe next few hours, his blood pressure fell, his breathing worsened,and he drifted from agitation to near-unconsciousness. Each of hisorgan systems, including his brain, was shutting down.

I called his sister, who was his next of kin, and told her of thesituation. "Do everything you can," she said.

So we did. We gave him a syringeful of anesthetic, and a resident slida breathing tube into his throat. Another resident "lined him up." Sheinserted a thin, two-inch-long needle and catheter through hisupturned right wrist and into his radial artery, and then sewed theline to his skin with a silk suture. Next, she put in a central line—atwelve-inch catheter pushed into the jugular vein in his left neck.After she sewed that in place, and an X-ray showed its tip floatingjust where it was supposed to—inside his vena cava at the entrance tohis heart—she put a third, slightly thicker line, for dialysis,through his right upper chest and into the subclavian vein, deep underthe collarbone.

We hooked a breathing tube up to a hose from a ventilator and set itto give him fourteen forced breaths of a hundred-per-cent oxygen everyminute. We dialled the ventilator pressures and gas flow up and down,like engineers at a control panel, until we got the blood levels ofoxygen and carbon dioxide where we wanted them. The arterial line gaveus continuous arterial blood-pressure measurements, and we tweaked hismedications to get the pressures we liked. We regulated hisintravenous fluids according to venous-pressure measurements from hisjugular line. We plugged his subclavian line into tubing from adialysis machine, and every few minutes his entire blood volume washedthrough this artificial kidney and back into his body; a littleadjustment here and there, and we could alter the levels of potassiumand bicarbonate and salt in his body as well. He was, we liked toimagine, a simple machine in our hands.

But he wasn't, of course. It was as if we had gained a steering wheeland a few gauges and controls, but on a runaway eighteen-wheelerhurtling down a mountain. Keeping his blood pressure normal wasrequiring gallons of intravenous fluid and a pharmacy shelf of drugs.He was on near-maximal ventilator support. His temperature climbed toa hundred and four degrees. Less than five per cent of patients withhis degree of organ failure make it home. And a single misstep couldeasily erase those slender chances.

For ten days, though, all went well. His chief problem had been liverdamage from the operation he'd had. The main duct from his liver wassevered and was leaking bile, which is caustic—it digests the fat inone's diet and was essentially eating him alive from the inside. Hehad become too sick to survive an operation to repair the leak. So wetried a temporary solution—we had radiologists place a plastic drain,using X-ray guidance, through his abdominal wall and into the severedduct in order to draw the leaking bile out of him. They found so muchthat they had to place three drains—one inside the duct and two aroundit. But, as the bile drained out, his fevers subsided. Hisrequirements for oxygen and fluids diminished. His blood pressurereturned to normal. He was on the mend. Then, on the eleventh day,just as we were getting ready to take him off the mechanicalventilator, he developed high, spiking fevers, his blood pressuresank, and his blood-oxygen levels plummeted again. His skin becameclammy. He got shaking chills.

We didn't understand what had happened. He seemed to have developed aninfection, but our X-rays and CT scans failed to turn up a source.Even after we put him on four antibiotics, he continued to spikefevers. During one fever, his heart went into fibrillation. A CodeBlue was called. A dozen nurses and doctors raced to his bedside,slapped electric paddles onto his chest, and shocked him. His heartresponded, fortunately, and went back into rhythm. It took two moredays for us to figure out what had gone wrong. We considered thepossibility that one of his lines had become infected, so we put innew lines and sent the old ones to the lab for culturing. Forty-eighthours later, the results returned: all of them were infected. Theinfection had probably started in one line, perhaps contaminatedduring insertion, and spread through his bloodstream to the others.Then they all began spilling bacteria into him, producing his feversand steep decline.

This is the reality of intensive care: at any point, we are as apt toharm as we are to heal. Line infections are so common that they areconsidered a routine complication. I.C.U.s put five million lines intopatients each year, and national statistics show that, after ten days,four per cent of those lines become infected. Line infections occur ineighty thousand people a year in the United States, and are fatalbetween five and twenty-eight per cent of the time, depending on howsick one is at the start. Those who survive line infections spend onaverage a week longer in intensive care. And this is just one of manyrisks. After ten days with a urinary catheter, four per cent ofAmerican I.C.U. patients develop a bladder infection. After ten dayson a ventilator, six per cent develop bacterial pneumonia, resultingin death forty to fifty-five per cent of the time. All in all, abouthalf of I.C.U. patients end up experiencing a serious complication,and, once a complication occurs, the chances of survival drop sharply.

It was a week before DeFilippo recovered sufficiently from hisinfections to come off the ventilator, and it was two months before heleft the hospital. Weak and debilitated, he lost his limousinebusiness and his home, and he had to move in with his sister. The tubedraining bile still dangled from his abdomen; when he was stronger, Iwas going to have to do surgery to reconstruct the main bile duct fromhis liver. But he survived. Most people in his situation do not.

Here, then, is the puzzle of I.C.U. care: you have a desperately sickpatient, and in order to have a chance of saving him you have to makesure that a hundred and seventy-eight daily tasks are doneright—despite some monitor's alarm going off for God knows whatreason, despite the patient in the next bed crashing, despite a nursepoking his head around the curtain to ask whether someone could help"get this lady's chest open." So how do you actually manage all thiscomplexity? The solution that the medical profession has favored isspecialization.

I tell DeFilippo's story, for instance, as if I were the one tendingto him hour by hour. But that was actually Max Weinmann, anintensivist (as intensive-care specialists like to be called). I wantto think that, as a general surgeon, I can handle most clinicalsituations. But, as the intricacies involved in intensive care havemounted, responsibility has increasingly shifted to super-specialistslike him. In the past decade, training programs focussed on criticalcare have opened in every major American city, and half of I.C.U.s nowrely on super-specialists.

Expertise is the mantra of modern medicine. In the early twentiethcentury, you needed only a high-school diploma and a one-year medicaldegree to practice medicine. By the century's end, all doctors had tohave a college degree, a four-year medical degree, and an additionalthree to seven years of residency training in an individual field ofpractice—pediatrics, surgery, neurology, or the like. Already, though,this level of preparation has seemed inadequate to the new complexityof medicine. After their residencies, most young doctors today aregoing on to do fellowships, adding one to three further years oftraining in, say, laparoscopic surgery, or pediatric metabolicdisorders, or breast radiology—or critical care. A young doctor is notso young nowadays; you typically don't start in independent practiceuntil your mid-thirties.

We now live in the era of the super-specialist—of clinicians who havetaken the time to practice at one narrow thing until they can do itbetter than anyone who hasn't. Super-specialists have two advantagesover ordinary specialists: greater knowledge of the details thatmatter and an ability to handle the complexities of the job. There aredegrees of complexity, though, and intensive-care medicine has grownso far beyond ordinary complexity that avoiding daily mistakes isproving impossible even for our super-specialists. The I.C.U., withits spectacular successes and frequent failures, therefore poses adistinctive challenge: what do you do when expertise is not enough?

On October 30, 1935, at Wright Air Field in Dayton, Ohio, the U.S.Army Air Corps held a flight competition for airplane manufacturersvying to build its next-generation long-range bomber. It wasn'tsupposed to be much of a competition. In early evaluations, the BoeingCorporation's gleaming aluminum-alloy Model 299 had trounced thedesigns of Martin and Douglas. Boeing's plane could carry five timesas many bombs as the Army had requested; it could fly faster thanprevious bombers, and almost twice as far. A Seattle newspaperman whohad glimpsed the plane called it the "flying fortress," and the namestuck. The flight "competition," according to the military historianPhillip Meilinger, was regarded as a mere formality. The Army plannedto order at least sixty-five of the aircraft.

A small crowd of Army brass and manufacturing executives watched asthe Model 299 test plane taxied onto the runway. It was sleek andimpressive, with a hundred-and-three-foot wingspan and four enginesjutting out from the wings, rather than the usual two. The planeroared down the tarmac, lifted off smoothly, and climbed sharply tothree hundred feet. Then it stalled, turned on one wing, and crashedin a fiery explosion. Two of the five crew members died, including thepilot, Major Ployer P. Hill.

An investigation revealed that nothing mechanical had gone wrong. Thecrash had been due to "pilot error," the report said. Substantiallymore complex than previous aircraft, the new plane required the pilotto attend to the four engines, a retractable landing gear, new wingflaps, electric trim tabs that needed adjustment to maintain controlat different airspeeds, and constant-speed propellers whose pitch hadto be regulated with hydraulic controls, among other features. Whiledoing all this, Hill had forgotten to release a new locking mechanismon the elevator and rudder controls. The Boeing model was deemed, as anewspaper put it, "too much airplane for one man to fly." The Army AirCorps declared Douglas's smaller design the winner. Boeing nearly wentbankrupt.

Still, the Army purchased a few aircraft from Boeing as test planes,and some insiders remained convinced that the aircraft was flyable. Soa group of test pilots got together and considered what to do.

They could have required Model 299 pilots to undergo more training.But it was hard to imagine having more experience and expertise thanMajor Hill, who had been the U.S. Army Air Corps' chief of flighttesting. Instead, they came up with an ingeniously simple approach:they created a pilot's checklist, with step-by-step checks fortakeoff, flight, landing, and taxiing. Its mere existence indicatedhow far aeronautics had advanced. In the early years of flight,getting an aircraft into the air might have been nerve-racking, but itwas hardly complex. Using a checklist for takeoff would no more haveoccurred to a pilot than to a driver backing a car out of the garage.But this new plane was too complicated to be left to the memory of anypilot, however expert.

With the checklist in hand, the pilots went on to fly the Model 299 atotal of 1.8 million miles without one accident. The Army ultimatelyordered almost thirteen thousand of the aircraft, which it dubbed theB-17. And, because flying the behemoth was now possible, the Armygained a decisive air advantage in the Second World War which enabledits devastating bombing campaign across Nazi Germany.

Medicine today has entered its B-17 phase. Substantial parts of whathospitals do—most notably, intensive care—are now too complex forclinicians to carry them out reliably from memory alone. I.C.U. lifesupport has become too much medicine for one person to fly.

Yet it's far from obvious that something as simple as a checklistcould be of much help in medical care. Sick people are phenomenallymore various than airplanes. A study of forty-one thousand traumapatients—just trauma patients—found that they had 1,224 differentinjury-related diagnoses in 32,261 unique combinations for teams toattend to. That's like having 32,261 kinds of airplane to land.Mapping out the proper steps for each is not possible, and physicianshave been skeptical that a piece of paper with a bunch of little boxeswould improve matters much.

In 2001, though, a critical-care specialist at Johns Hopkins Hospitalnamed Peter Pronovost decided to give it a try. He didn't attempt tomake the checklist cover everything; he designed it to tackle just oneproblem, the one that nearly killed Anthony DeFilippo: lineinfections. On a sheet of plain paper, he plotted out the steps totake in order to avoid infections when putting a line in. Doctors aresupposed to (1) wash their hands with soap, (2) clean the patient'sskin with chlorhexidine antiseptic, (3) put sterile drapes over theentire patient, (4) wear a sterile mask, hat, gown, and gloves, and(5) put a sterile dressing over the catheter site once the line is in.Check, check, check, check, check. These steps are no-brainers; theyhave been known and taught for years. So it seemed silly to make achecklist just for them. Still, Pronovost asked the nurses in hisI.C.U. to observe the doctors for a month as they put lines intopatients, and record how often they completed each step. In more thana third of patients, they skipped at least one.

The next month, he and his team persuaded the hospital administrationto authorize nurses to stop doctors if they saw them skipping a stepon the checklist; nurses were also to ask them each day whether anylines ought to be removed, so as not to leave them in longer thannecessary. This was revolutionary. Nurses have always had their waysof nudging a doctor into doing the right thing, ranging from thegentle reminder ("Um, did you forget to put on your mask, doctor?") tomore forceful methods (I've had a nurse bodycheck me when she thoughtI hadn't put enough drapes on a patient). But many nurses aren't surewhether this is their place, or whether a given step is worth aconfrontation. (Does it really matter whether a patient's legs aredraped for a line going into the chest?) The new rule made it clear:if doctors didn't follow every step on the checklist, the nurses wouldhave backup from the administration to intervene.

Pronovost and his colleagues monitored what happened for a yearafterward. The results were so dramatic that they weren't sure whetherto believe them: the ten-day line-infection rate went from eleven percent to zero. So they followed patients for fifteen more months. Onlytwo line infections occurred during the entire period. They calculatedthat, in this one hospital, the checklist had prevented forty-threeinfections and eight deaths, and saved two million dollars in costs.

Pronovost recruited some more colleagues, and they made some morechecklists. One aimed to insure that nurses observe patients for painat least once every four hours and provide timely pain medication.This reduced the likelihood of a patient's experiencing untreated painfrom forty-one per cent to three per cent. They tested a checklist forpatients on mechanical ventilation, making sure that, for instance,the head of each patient's bed was propped up at least thirty degreesso that oral secretions couldn't go into the windpipe, and antacidmedication was given to prevent stomach ulcers. The proportion ofpatients who didn't receive the recommended care dropped from seventyper cent to four per cent; the occurrence of pneumonias fell by aquarter; and twenty-one fewer patients died than in the previous year.The researchers found that simply having the doctors and nurses in theI.C.U. make their own checklists for what they thought should be doneeach day improved the consistency of care to the point that, within afew weeks, the average length of patient stay in intensive caredropped by half.

The checklists provided two main benefits, Pronovost observed. First,they helped with memory recall, especially with mundane matters thatare easily overlooked in patients undergoing more drastic events.(When you're worrying about what treatment to give a woman who won'tstop seizing, it's hard to remember to make sure that the head of herbed is in the right position.) A second effect was to make explicitthe minimum, expected steps in complex processes. Pronovost wassurprised to discover how often even experienced personnel failed tograsp the importance of certain precautions. In a survey of I.C.U.staff taken before introducing the ventilator checklists, he foundthat half hadn't realized that there was evidence strongly supportinggiving ventilated patients antacid medication. Checklists establisheda higher standard of baseline performance.

These are, of course, ridiculously primitive insights. Pronovost isroutinely described by colleagues as "brilliant," "inspiring," a"genius." He has an M.D. and a Ph.D. in public health from JohnsHopkins, and is trained in emergency medicine, anesthesiology, andcritical-care medicine. But, really, does it take all that to figureout what house movers, wedding planners, and tax accountants figuredout ages ago?

Pronovost is hardly the first person in medicine to use a checklist.But he is among the first to recognize its power to save lives andtake advantage of the breadth of its possibilities. Forty-two yearsold, with cropped light-brown hair, tenth-grader looks, and afluttering, finchlike energy, he is an odd mixture of the nerdy andthe messianic. He grew up in Waterbury, Connecticut, the son of anelementary-school teacher and a math professor, went to nearbyFairfield University, and, like many good students, decided that hewould go into medicine. Unlike many students, though, he found that heactually liked caring for sick people. He hated the laboratory—withall those micropipettes and cell cultures, and no patients around—buthe had that scientific "How can I solve this unsolved problem?" turnof mind. So after his residency in anesthesiology and his fellowshipin critical care, he studied clinical-research methods.

For his doctoral thesis, he examined intensive-care units in Maryland,and he discovered that putting an intensivist on staff reduced deathrates by a third. It was the first time that someone had demonstratedthe public-health value of using intensivists. He wasn't satisfiedwith having proved his case, though; he wanted hospitals to changeaccordingly. After his study was published, in 1999, he met with acoalition of large employers known as the Leapfrog Group. It includedcompanies like General Motors and Verizon, which were seeking toimprove the standards of hospitals where their employees obtain care.Within weeks, the coalition announced that its members expected thehospitals they contracted with to staff their I.C.U.s withintensivists. These employers pay for health care for thirty-sevenmillion employees, retirees, and dependents nationwide. So althoughhospitals protested that there weren't enough intensivists to goaround, and that the cost could be prohibitive, Pronovost's ideaeffectively became an instant national standard.

The scientist in him has always made room for the campaigner. Peoplesay he is the kind of guy who, even as a trainee, could make you feelyou'd saved the world every time you washed your hands properly. "I'venever seen anybody inspire as he does," Marty Makary, a Johns Hopkinssurgeon, told me. "Partly, he has this contagious, excitable nature.He has a smile that's tough to match. But he also has a way of makingpeople feel heard. People will come to him with the dumbest ideas, andhe'll endorse them anyway. `Oh, I like that, I like that, I likethat!' he'll say. I've watched him, and I still have no idea howdeliberate this is. Maybe he really does like every idea. But wait,and you realize: he only acts on the ones he truly believes in."

After the checklist results, the idea Pronovost truly believed in wasthat checklists could save enormous numbers of lives. He took hisfindings on the road, showing his checklists to doctors, nurses,insurers, employers—anyone who would listen. He spoke in an average ofseven cities a month while continuing to work full time in JohnsHopkins's I.C.U.s. But this time he found few takers.

There were various reasons. Some physicians were offended by thesuggestion that they needed checklists. Others had legitimate doubtsabout Pronovost's evidence. So far, he'd shown only that checklistsworked in one hospital, Johns Hopkins, where the I.C.U.s have money,plenty of staff, and Peter Pronovost walking the hallways to make surethat the checklists are being used properly. How about in the realworld—where I.C.U. nurses and doctors are in short supply, pressed fortime, overwhelmed with patients, and hardly receptive to the idea offilling out yet another piece of paper?

In 2003, however, the Michigan Health and Hospital Association askedPronovost to try out three of his checklists in Michigan's I.C.U.s. Itwould be a huge undertaking. Not only would he have to get the state'shospitals to use the checklists; he would also have to measure whetherdoing so made a genuine difference. But at last Pronovost had a chanceto establish whether his checklist idea really worked.

This past summer, I visited Sinai-Grace Hospital, in inner-cityDetroit, and saw what Pronovost was up against. Occupying a campus ofred brick buildings amid abandoned houses, check-cashing stores, andwig shops on the city's West Side, just south of 8 Mile Road,Sinai-Grace is a classic urban hospital. It has eight hundredphysicians, seven hundred nurses, and two thousand other medicalpersonnel to care for a population with the lowest median income ofany city in the country. More than a quarter of a million residentsare uninsured; three hundred thousand are on state assistance. Thathas meant chronic financial problems. Sinai-Grace is not the mostcash-strapped hospital in the city—that would be Detroit ReceivingHospital, where a fifth of the patients have no means of payment. Butbetween 2000 and 2003 Sinai-Grace and eight other Detroit hospitalswere forced to cut a third of their staff, and the state had to comeforward with a fifty-million-dollar bailout to avert their bankruptcy.

Sinai-Grace has five I.C.U.s for adult patients and one for infants.Hassan Makki, the director of intensive care, told me what it was likethere in 2004, when Pronovost and the hospital association started aseries of mailings and conference calls with hospitals to introducechecklists for central lines and ventilator patients. "Morale waslow," he said. "We had lost lots of staff, and the nurses who remainedweren't sure if they were staying." Many doctors were thinking aboutleaving, too. Meanwhile, the teams faced an even heavier workloadbecause of new rules limiting how long the residents could work at astretch. Now Pronovost was telling them to find the time to fill outsome daily checklists?

Tom Piskorowski, one of the I.C.U. physicians, told me his reaction:"Forget the paperwork. Take care of the patient."

I accompanied a team on 7 A.M. rounds through one of the surgicalI.C.U.s. It had eleven patients. Four had gunshot wounds (one had beenshot in the chest; one had been shot through the bowel, kidney, andliver; two had been shot through the neck, and left quadriplegic).Five patients had cerebral hemorrhaging (three were seventy-nine yearsand older and had been injured falling down stairs; one was amiddle-aged man whose skull and left temporal lobe had been damaged byan assault with a blunt weapon; and one was a worker who had becomeparalyzed from the neck down after falling twenty-five feet off aladder onto his head). There was a cancer patient recovering fromsurgery to remove part of his lung, and a patient who had had surgeryto repair a cerebral aneurysm.

The doctors and nurses on rounds tried to proceed methodically fromone room to the next but were constantly interrupted: a patient theythought they'd stabilized began hemorrhaging again; another who hadbeen taken off the ventilator developed trouble breathing and had tobe put back on the machine. It was hard to imagine that they could gettheir heads far enough above the daily tide of disasters to worryabout the minutiae on some checklist.

Yet there they were, I discovered, filling out those pages. Mostly, itwas the nurses who kept things in order. Each morning, a senior nursewalked through the unit, clipboard in hand, making sure that everypatient on a ventilator had the bed propped at the right angle, andhad been given the right medicines and the right tests. Wheneverdoctors put in a central line, a nurse made sure that the central-linechecklist had been filled out and placed in the patient's chart.Looking back through their files, I found that they had been doingthis faithfully for more than three years.

Pronovost had been canny when he started. In his first conversationswith hospital administrators, he didn't order them to use thechecklists. Instead, he asked them simply to gather data on their owninfection rates. In early 2004, they found, the infection rates forI.C.U. patients in Michigan hospitals were higher than the nationalaverage, and in some hospitals dramatically so. Sinai-Graceexperienced more line infections than seventy-five per cent ofAmerican hospitals. Meanwhile, Blue Cross Blue Shield of Michiganagreed to give hospitals small bonus payments for participating inPronovost's program. A checklist suddenly seemed an easy and logicalthing to try.

In what became known as the Keystone Initiative, each hospitalassigned a project manager to roll out the checklists and participatein a twice-monthly conference call with Pronovost fortrouble-shooting. Pronovost also insisted that each participatinghospital assign to each unit a senior hospital executive, who wouldvisit the unit at least once a month, hear people's complaints, andhelp them solve problems.

The executives were reluctant. They normally lived in meetingsworrying about strategy and budgets. They weren't used to venturinginto patient territory and didn't feel that they belonged there. Insome places, they encountered hostility. But their involvement provedcrucial. In the first month, according to Christine Goeschel, at thetime the Keystone Initiative's director, the executives discoveredthat the chlorhexidine soap, shown to reduce line infections, wasavailable in fewer than a third of the I.C.U.s. This was a problemonly an executive could solve. Within weeks, every I.C.U. in Michiganhad a supply of the soap. Teams also complained to the hospitalofficials that the checklist required that patients be fully coveredwith a sterile drape when lines were being put in, but full-sizebarrier drapes were often unavailable. So the officials made sure thatthe drapes were stocked. Then they persuaded Arrow International, oneof the largest manufacturers of central lines, to produce a newcentral-line kit that had both the drape and chlorhexidine in it.

In December, 2006, the Keystone Initiative published its findings in alandmark article in The New England Journal of Medicine. Within thefirst three months of the project, the infection rate in Michigan'sI.C.U.s decreased by sixty-six per cent. The typical I.C.U.—includingthe ones at Sinai-Grace Hospital—cut its quarterly infection rate tozero. Michigan's infection rates fell so low that its average I.C.U.outperformed ninety per cent of I.C.U.s nationwide. In the KeystoneInitiative's first eighteen months, the hospitals saved an estimatedhundred and seventy-five million dollars in costs and more thanfifteen hundred lives. The successes have been sustained for almostfour years—all because of a stupid little checklist.

Pronovost's results have not been ignored. He has since had requeststo help Rhode Island, New Jersey, and the country of Spain do whatMichigan did. Back in the Wolverine State, he and the KeystoneInitiative have begun testing half a dozen additional checklists toimprove care for I.C.U. patients. He has also been asked to develop aprogram for surgery patients. It has all become more than he and hissmall group of researchers can keep up with.

But consider: there are hundreds, perhaps thousands, of things doctorsdo that are at least as dangerous and prone to human failure asputting central lines into I.C.U. patients. It's true of cardiac care,stroke treatment, H.I.V. treatment, and surgery of all kinds. It'salso true of diagnosis, whether one is trying to identify cancer orinfection or a heart attack. All have steps that are worth putting ona checklist and testing in routine care. The question—stillunanswered—is whether medical culture will embrace the opportunity.

Tom Wolfe's "The Right Stuff" tells the story of our first astronauts,and charts the demise of the maverick, Chuck Yeager test-pilot cultureof the nineteen-fifties. It was a culture defined by how unbelievablydangerous the job was. Test pilots strapped themselves into machinesof barely controlled power and complexity, and a quarter of them werekilled on the job. The pilots had to have focus, daring, wits, and anability to improvise—the right stuff. But as knowledge of how tocontrol the risks of flying accumulated—as checklists and flightsimulators became more prevalent and sophisticated—the dangerdiminished, values of safety and conscientiousness prevailed, and therock-star status of the test pilots was gone.

Something like this is going on in medicine. We have the means to makesome of the most complex and dangerous work we do—in surgery,emergency care, and I.C.U. medicine—more effective than we everthought possible. But the prospect pushes against the traditionalculture of medicine, with its central belief that in situations ofhigh risk and complexity what you want is a kind of expertaudacity—the right stuff, again. Checklists and standard operatingprocedures feel like exactly the opposite, and that's what ranklesmany people.

It's ludicrous, though, to suppose that checklists are going to doaway with the need for courage, wits, and improvisation. The body istoo intricate and individual for that: good medicine will not be ableto dispense with expert audacity. Yet it should also be ready toaccept the virtues of regimentation.

The still limited response to Pronovost's work may be easy to explain,but it is hard to justify. If someone found a new drug that could wipeout infections with anything remotely like the effectiveness ofPronovost's lists, there would be television ads with Robert Jarvikextolling its virtues, detail men offering free lunches to get doctorsto make it part of their practice, government programs to research it,and competitors jumping in to make a newer, better version. That'swhat happened when manufacturers marketed central-line catheterscoated with silver or other antimicrobials; they cost a third more,and reduced infections only slightly—and hospitals have spent tens ofmillions of dollars on them. But, with the checklist, what we have isPeter Pronovost trying to see if maybe, in the next year or two,hospitals in Rhode Island and New Jersey will give his idea a try.

Pronovost remains, in a way, an odd bird in medical research. He doesnot have the multimillion-dollar grants that his colleagues in benchscience have. He has no swarm of doctoral students and lab animals.He's focussed on work that is not normally considered a significantcontribution in academic medicine. As a result, few other researchersare venturing to extend his achievements. Yet his work has alreadysaved more lives than that of any laboratory scientist in the past decade.

I called Pronovost recently at Johns Hopkins, where he was on duty inan I.C.U. I asked him how long it would be before the average doctoror nurse is as apt to have a checklist in hand as a stethoscope(which, unlike checklists, has never been proved to make a differenceto patient care).

"At the current rate, it will never happen," he said, as monitorsbeeped in the background. "The fundamental problem with the quality ofAmerican medicine is that we've failed to view delivery of health careas a science. The tasks of medical science fall into three buckets.One is understanding disease biology. One is finding effectivetherapies. And one is insuring those therapies are deliveredeffectively. That third bucket has been almost totally ignored byresearch funders, government, and academia. It's viewed as the art ofmedicine. That's a mistake, a huge mistake. And from a taxpayer'sperspective it's outrageous." We have a thirty-billion-dollar-a-yearNational Institutes of Health, he pointed out, which has been aremarkable powerhouse of discovery. But we have no billion-dollarNational Institute of Health Care Delivery studying how best toincorporate those discoveries into daily practice.

I asked him how much it would cost for him to do for the whole countrywhat he did for Michigan. About two million dollars, he said, maybethree, mostly for the technical work of signing up hospitals toparticipate state by state and coördinating a database to track theresults. He's already devised a plan to do it in all of Spain for less.

"We could get I.C.U. checklists in use throughout the United Stateswithin two years, if the country wanted it," he said.

So far, it seems, we don't. The United States could have been thefirst to adopt medical checklists nationwide, but, instead, Spain willbeat us. "I at least hope we're not the last," Pronovost said.

Recently, I spoke to Markus Thalmann, the cardiac surgeon on the teamthat saved the little Austrian girl who had drowned, and learned thata checklist had been crucial to her survival. Thalmann had worked forsix years at the city hospital in Klagenfurt, the small provincialcapital in south Austria where the girl was resuscitated. She was notthe first person whom he and his colleagues had tried to revive fromcardiac arrest after hypothermia and suffocation. They receivedbetween three and five such patients a year, he estimated, mostlyavalanche victims (Klagenfurt is surrounded by the Alps), some of themdrowning victims, and a few of them people attempting suicide bytaking a drug overdose and then wandering out into the snowy foreststo fall unconscious.

For a long time, he said, no matter how hard the medical team tried,it had no survivors. Most of the victims had gone without a pulse andoxygen for too long by the time they were found. But some, he felt,still had a flicker of viability in them, and each time the teamfailed to sustain it.

Speed was the chief difficulty. Success required having an array ofequipment and people at the ready—helicopter-rescue personnel, traumasurgeons, an experienced cardiac anesthesiologist and surgeon,bioengineering support staff, operating and critical-care nurses,intensivists. Too often, someone or something was missing. So he and acouple of colleagues made and distributed a checklist. In cases likethese, the checklist said, rescue teams were to tell the hospital toprepare for possible cardiac bypass and rewarming. They were to call,when possible, even before they arrived on the scene, as thepreparation time could be significant. The hospital would then workdown a list of people to be notified. They would have an operatingroom set up and standing by.

The team had its first success with the checklist in place—the rescueof the three-year-old girl. Not long afterward, Thalmann left to takea job at a hospital in Vienna. The team, however, was able to make atleast two other such rescues, he said. In one case, a man was foundfrozen and pulseless after a suicide attempt. In another, a mother andher sixteen-year-old daughter were in an accident that sent them andtheir car through a guardrail, over a cliff, and into a mountainriver. The mother died on impact; the daughter was trapped as the carrapidly filled with icy water. She had been in cardiac and respiratoryarrest for a prolonged period of time when the rescue team arrived.

From that point onward, though, the system went like clockwork. By thetime the rescue team got to her and began CPR, the hospital had beennotified. The transport team got her there in minutes. The surgicalteam took her straight to the operating room and crashed her ontoheart-lung bypass. One step went right after another. And, because ofthe speed with which they did, she had a chance.

As the girl's body slowly rewarmed, her heart came back. In theI.C.U., a mechanical ventilator, fluids, and intravenous drugs kepther going while the rest of her body recovered. The next day, thedoctors were able to remove her lines and tubes. The day after that,she was sitting up in bed, ready to go home. &#9830;